Florida Senate (PROPOSED BILL) SPB 7044

Transcription

1 FOR CONSIDERATION By the Committee on Health Policy A bill to be entitled An act relating to a health insurance affordability exchange; creating s , F.S.; providing a short title; creating s , F.S.; creating the Florida Health Insurance Affordability Exchange Program or FHIX in the Agency for Health Care Administration; providing program authority and principles; creating s , F.S.; defining terms; creating s , F.S.; providing eligibility and enrollment criteria; providing patient rights and responsibilities; providing premium levels; creating s , F.S.; providing for premium credits and choice counseling; establishing an education campaign; providing for customer support and disenrollment; creating s , F.S.; providing for available products and services; creating s , F.S.; providing for program accountability; creating s , F.S.; providing an implementation schedule; creating s , F.S.; providing program operation and management duties; creating s , F.S.; providing for the development of a long-term reorganization plan and the formation of the FHIX Workgroup; creating s , F.S.; authorizing the agency to seek federal approval; creating s , F.S.; providing for program expiration; repealing s , F.S., relating to legislative findings regarding access to affordable health care; amending s , F.S.; revising legislative intent; redefining terms; revising the scope of the Florida Page 1 of 49

2 Health Choices Program and the pricing of services under the program; providing requirements for operation of the marketplace; providing additional duties for the corporation to perform; requiring an annual report to the Governor and the Legislature; amending s , F.S.; removing certain Medicaideligible persons from those for whom the agency may make payments for medical assistance and related services; amending s , F.S.; revising eligibility requirements for state-funded assistance; revising the duties and powers of the Florida Healthy Kids Corporation; revising provisions for the appointment of members of the board of the Florida Healthy Kids Corporation; requiring transition plans; repealing s , F.S., relating to the operating fund of the Florida Healthy Kids Corporation; providing an effective date. Be It Enacted by the Legislature of the State of Florida: Section 1. The Division of Law Revision and Information is directed to rename part II of chapter 409, Florida Statutes, as Insurance Affordability Programs and to incorporate ss , Florida Statutes, under this part. Section 2. Section , Florida Statutes, is created to read: Short title. Sections may be cited as the Florida Health Insurance Affordability Exchange Program or FHIX. Page 2 of 49

3 Section 3. Section , Florida Statutes, is created to read: Program authority. The Florida Health Insurance Affordability Exchange Program, or FHIX, is created in the agency to assist Floridians in purchasing health benefits coverage and gaining access to health services. The products and services offered by FHIX are based on the following principles: (1) FAIR VALUE. Financial assistance will be rationally allocated regardless of differences in categorical eligibility. (2) CONSUMER CHOICE. Participants will be offered meaningful choices in the way they can redeem the value of the available assistance. (3) SIMPLICITY. Obtaining assistance will be consumerfriendly, and customer support will be available when needed. (4) PORTABILITY. Participants can continue to access the services and products of FHIX despite changes in their circumstances. (5) PROMOTES EMPLOYMENT. Assistance will be offered in a way that incentivizes employment. (6) CONSUMER EMPOWERMENT. Assistance will be offered in a manner that maximizes individual control over available resources. (7) RISK ADJUSTMENT. The amount of assistance will reflect participants medical risk. Section 4. Section , Florida Statutes, is created to read: Definitions. As used in ss , the term: (1) Agency means the Agency for Health Care Page 3 of 49

4 Administration. (2) Applicant means an individual who applies for determination of eligibility for health benefits coverage under this part. (3) Corporation means Florida Health Choices, Inc., as established under s (4) Enrollee means an individual who has been determined eligible for and is receiving health benefits coverage under this part. (5) FHIX marketplace or marketplace means the single, centralized market established under s which facilitates health benefits coverage. (6) Florida Health Insurance Affordability Exchange Program or FHIX means the program created under ss (7) Florida Healthy Kids Corporation means the entity created under s (8) Florida Kidcare program or Kidcare program means the health benefits coverage administered through ss (9) Health benefits coverage means the payment of benefits for covered health care services or the availability, directly or through arrangements with other persons, of covered health care services on a prepaid per capita basis or on a prepaid aggregate fixed-sum basis. (10) Inactive status means the enrollment status of a participant previously enrolled in health benefits coverage through the FIX marketplace who lost coverage through the marketplace for non-payment, but maintains access to his or her Page 4 of 49

5 balance in a health savings account or health reimbursement account. (11) Medicaid means the medical assistance program authorized by Title XIX of the Social Security Act, and regulations thereunder, and part III and part IV of this chapter, as administered in this state by the agency. (l2) Modified adjusted gross income means the individual s or household s annual adjusted gross income as defined in s. 36B(d)(2) of the Internal Revenue Code of 1986 and which is used to determine eligibility for FHIX. (13) Patient Protection and Affordable Care Act or Affordable Care Act means Pub. L. No , as further amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No , and any amendments to, and regulations or guidance under, those acts. (14) Premium credit means the monthly amount paid by the agency per enrollee in the Florida Health Insurance Affordability Exchange Program toward health benefits coverage. (15) Qualified alien means an alien as defined in 8 U.S.C. s. 1641(b) or (c). (16) Resident means a United States citizen or qualified alien who is domiciled in this state. Section 5. Section , Florida Statutes, is created to read: Participation. (1) ELIGIBILITY. In order to participate in FHIX, an individual must be a resident and must meet the following requirements, as applicable: (a) Qualify as a newly eligible enrollee, who must be an Page 5 of 49

6 individual as described in s. 1902(a)(10)(A)(i)(VIII) of the Social Security Act or s of the Affordable Care Act and as may be further defined by federal regulation. (b) Meet and maintain the responsibilities under subsection (4). (c) Qualify as a participant in the Florida Healthy Kids program under s , subject to the implementation of Phase Three under s (2) ENROLLMENT. To enroll in FHIX, an applicant must submit an application to the department for an eligibility determination. (a) Applications may be submitted by mail, fax, online, or any other method permitted by law or regulation. (b) The department is responsible for any eligibility correspondence and status updates to the participant and other agencies. (c) The department shall review a participant s eligibility every 12 months. (d) An application or renewal is deemed complete when the participant has met all the requirements under subsection (4). (3) PARTICIPANT RIGHTS. A participant has all of the following rights: (a) Access to the FHIX marketplace to select the scope, amount, and type of health care coverage and other services to purchase. (b) Continuity and portability of coverage to avoid disruption of coverage and other health care services when the participant s economic circumstances change. (c) Retention of applicable unspent credits in the Page 6 of 49

7 participant s health savings or health reimbursement account following a change in the participant s eligibility status. Credits are valid for an inactive status participant for up to 5 years after the participant first enters an inactive status. (d) Ability to select more than one product or plan on the FHIX marketplace. (e) Choice of at least two health benefits products that meet the requirements of the Affordable Care Act. (4) PARTICIPANT RESPONSIBILITIES. A participant has all of the following responsibilities: (a) Complete an initial application for health benefits coverage and an annual renewal process, which includes proof of employment, on-the-job training or placement activities, or pursuit of educational opportunities at the following hourly levels: 1. For a parent of a child younger than 18 years of age, a minimum of 20 hours weekly. 2. For a childless adult, a minimum of 30 hours weekly. A disabled adult or caregiver of a disabled child or adult may submit a request for an exception to these requirements to the corporation. A participant shall annually submit to the department such a request for an exception to the hourly level requirements. (b) Learn and remain informed about the choices available on the FHIX marketplace and the uses of credits in the individual accounts. (c) Execute a contract with the department to acknowledge that: 1. FHIX is not an entitlement and state and federal funding Page 7 of 49

8 may end at any time; 2. Failure to pay required premiums or cost sharing will result in a transition to inactive status; and 3. Noncompliance with work or educational requirements will result in a transition to inactive status. (d) Select plans and other products in a timely manner. (e) Comply with all program rules and the prohibitions against fraud, as described in s (f) Make monthly premium and any other cost-sharing payments by the deadline. (g) Meet minimum coverage requirements by selecting a highdeductible health plan combined with a health savings or health reimbursement account if not selecting a plan with more extensive coverage. (5) COST SHARING. (a) Enrollees are assessed monthly premiums based on their modified adjusted gross income. The maximum monthly premium payments are set at the following income levels: 1. At or below 22 percent of the federal poverty level: $3. 2. Greater than 22 percent, but at or below 50 percent, of the federal poverty level: $8. 3. Greater than 50 percent, but at or below 75 percent, of the federal poverty level: $ Greater than 75 percent, but at or below 100 percent, of the federal poverty level: $ Greater than 100 percent of the federal poverty level: $25. (b) Depending on the products and services selected by the enrollee, the enrollee may also incur additional cost-sharing Page 8 of 49

9 copayments, deductibles, or other out-of-pocket costs. (c) An enrollee may be subject to an inappropriate emergency room visit charge of up to $8 for the first visit and up to $25 for any subsequent visit, based on the enrollee s benefit plan, to discourage inappropriate use of the emergency room. (d) Cumulative annual cost sharing per enrollee may not exceed 5 percent of an enrollee s annual modified adjusted gross income. (e) If, after a 30-day grace period, a full premium payment has not been received, the enrollee shall be transitioned from coverage to inactive status and may not reenroll for a minimum of 6 months, unless a hardship exception has been granted. Enrollees may seek a hardship exception under the Medicaid Fair Hearing Process. Section 6. Section , Florida Statutes, is created to read: Available assistance. (1) PREMIUM CREDITS. (a) Standard amount. The standard monthly premium credit is equivalent to the applicable risk-adjusted capitation rate paid to Medicaid managed care plans under part IV of this chapter. (b) Supplemental funding. Subject to federal approval, additional resources may be made available to enrollees and incorporated into FHIX. (c) Savings accounts. In addition to the benefits provided under this section, the corporation must offer each enrollee access to an individual account that qualifies as a health reimbursement account or a health savings account. Eligible Page 9 of 49

10 unexpended funds from the monthly premium credit must be deposited into each enrollee s individual account in a timely manner. Enrollees may also be rewarded for healthy behaviors, adherence to wellness programs, and other activities established by the corporation which demonstrate compliance with prevention or disease management guidelines. Funds deposited into these accounts may be used to pay cost-sharing obligations or to purchase other health-related items to the extent permitted under federal law. (d) Enrollee contributions. The enrollee may make deposits to his or her account at any time to supplement the premium credit, to purchase additional FHIX products, or to offset other cost-sharing obligations. (e) Third parties. Third parties, including, but not limited to, an employer or relative, may also make deposits on behalf of the enrollee into the enrollee s FHIX marketplace account. The enrollee may not withdraw any funds as a refund, except those funds the enrollee has deposited into his or her account. (2) CHOICE COUNSELING. The agency and the corporation shall work together to develop a choice counseling program for FHIX. The choice counseling program must ensure that participants have information about the FHIX marketplace program, products, and services and that participants know where and whom to call for questions or to make their plan selections. The choice counseling program must provide culturally sensitive materials and must take into consideration the demographics of the projected population. (3) EDUCATION CAMPAIGN. The agency, the corporation, and Page 10 of 49

11 the Florida Healthy Kids Corporation must coordinate an ongoing enrollee education campaign beginning in Phase One, as provided in s , informing participants, at a minimum: (a) How the transition process to the FHIX marketplace will occur and the timeline for the enrollee s specific transition. (b) What plans are available and how to research information about available plans. (c) Information about other available insurance affordability programs for the individual and his or her family. (d) Information about health benefits coverage, provider networks, and cost sharing for available plans in each region. (e) Information on how to complete the required annual renewal process, including renewal dates and deadlines. (f) Information on how to update eligibility if the participant s data have changed since his or her last renewal or application date. (4) CUSTOMER SUPPORT. Beginning in Phase Two, the Florida Healthy Kids Corporation shall provide customer support for FHIX, shall address general program information, financial information, and customer service issues, and shall provide status updates on bill payments. Customer support must also provide a toll-free number and maintain a website that is available in multiple languages and that meets the needs of the enrollee population. (5) INACTIVE PARTICIPANTS. The corporation must inform the inactive participant about other insurance affordability programs and electronically refer the participant to the federal exchange or other insurance affordability programs, as appropriate. Page 11 of 49

12 Section 7. Section , Florida Statutes, is created to read: Available products and services. The FHIX marketplace shall offer the following products and services: (1) Authorized products and services pursuant to s (2) Medicaid managed care plans under part IV of this chapter. (3) Authorized products under the Florida Healthy Kids Corporation pursuant to s (4) Employer-sponsored plans. Section 8. Section , Florida Statutes, is created to read: Program accountability. (1) All managed care plans that participate in FHIX must collect and maintain encounter level data in accordance with the encounter data requirements under s (2)(d) and are subject to the accompanying penalties under s (2)(h)2. The agency is responsible for the collection and maintenance of the encounter level data. (2) The corporation, in consultation with the agency, shall establish access and network standards for contracts on the FHIX marketplace and shall ensure that contracted plans have sufficient providers to meet enrollee needs. The corporation, in consultation with the agency, shall develop quality of coverage and provider standards specific to the adult population. (3) The department shall develop accountability measures and performance standards to be applied to applications and renewal applications for FHIX which are submitted online, by Page 12 of 49

13 mail, by fax, or through referrals from a third party. The minimum performance standards are: (a) Application processing speed. Ninety percent of all applications, from all sources, must be processed within 45 days. (b) Applications processing speed from online sources. Ninety-five percent of all applications received from online sources must be processed within 45 days. (c) Renewal application processing speed. Ninety percent of all renewals, from all sources, must be processed within 45 days. (d) Renewal application processing speed from online sources. Ninety-five percent of all applications received from online sources must be processed within 45 days. (4) The agency, the department, and the Florida Healthy Kids Corporation must meet the following standards for their respective roles in the program: (a) Eighty-five percent of calls must be answered in 20 seconds or less. (b) One hundred percent of all contacts, which include, but are not limited to, telephone calls, faxed documents and requests, and s, must be handled within 2 business days. (c) Any self-service tools available to participants, such as interactive voice response systems, must be operational 7 days a week, 24 hours a day, at least 98 percent of each month. (5) The agency, the department, and the Florida Healthy Kids Corporation must conduct an annual satisfaction survey to address all measures that require participant input specific to the FHIX marketplace program. The parties may elect to Page 13 of 49

14 incorporate these elements into the annual report required under subsection (7). (6) The agency and the corporation shall post online monthly enrollment reports for FHIX. (7) An annual report is due no later than July 1 to the Governor, the President of the Senate, and the Speaker of the House of Representatives. The annual report must be coordinated by the agency and the corporation and must include, but is not limited to: (a) Enrollment and application trends and issues. (b) Utilization and cost data. (c) Customer satisfaction. (d) Funding sources in health savings accounts or health reimbursement accounts. (e) Enrollee use of funds in health savings accounts or health reimbursement accounts. (f) Types of products and plans purchased. (g) Movement of enrollees across different insurance affordability programs. (h) Recommendations for program improvement. Section 9. Section , Florida Statutes, is created to read: Implementation schedule. The agency, the corporation, the department, and the Florida Healthy Kids Corporation shall begin implementation of FHIX by the effective date of this act, with statewide implementation in all regions, as described in s (2), by January 1, (1) READINESS REVIEW. Before implementation of any phase under this section, the agency shall conduct a readiness review Page 14 of 49

15 in consultation with the FHIX Workgroup described in s The agency must determine that the region has satisfied, at a minimum, the following readiness milestones: (a) Functional readiness of the service delivery platform for the phase. (b) Plan availability and presence of plan choice. (c) Provider network capacity and adequacy of the available plans in the region. (d) Availability of customer support. (e) Other factors critical to the success of FHIX. (2) PHASE ONE. (a) Phase One begins on July 1, The agency, the corporation, and the Florida Healthy Kids Corporation shall coordinate activities to ensure that enrollment begins by July 1, (b) To be eligible during this phase, a participant must meet the requirements under s (1)(a). (c) An enrollee is entitled to receive health benefits coverage in the same manner as provided under and through the selected managed care plans in the Medicaid managed care program in part IV of this chapter. (d) An enrollee shall have a choice of at least two managed care plans in each region. (e) Choice counseling and customer service must be provided in accordance with s (2). (3) PHASE TWO. (a) Beginning no later than January 1, 2016, and contingent upon federal approval, participants may enroll or transition to health benefits coverage under the FHIX marketplace. Page 15 of 49

16 (b) To be eligible during this phase, a participant must meet the requirements under s (1)(a) and (b). (c) An enrollee may select any benefit, service, or product available. (d) The corporation shall notify an enrollee of his or her premium credit amount and how to access the FHIX marketplace selection process. (e) A Phase One enrollee must be transitioned to the FHIX marketplace by April 1, An enrollee who does not select a plan or service on the FHIX marketplace by that deadline shall be moved to inactive status. (f) An enrollee shall have a choice of at least two managed care plans in each region which meet or exceed the Affordable Care Act s requirements and which qualify for a premium credit on the FHIX marketplace. (g) Choice counseling and customer service must be provided in accordance with s (2) and (4). (4) PHASE THREE. (a) No later than July 1, 2016, the corporation and the Florida Healthy Kids Corporation must begin the transition of enrollees under s to the FHIX marketplace. (b) Eligibility during this phase is based on meeting the requirements of Phase II and s (1)(c). (c) An enrollee may select any benefit, service, or product available under s (d) A Florida Healthy Kids enrollee who selects a FHIX marketplace plan must be provided a premium credit equivalent to the average capitation rate paid in his or her county of residence under Florida Healthy Kids as of June 30, The Page 16 of 49

17 enrollee is responsible for any difference in costs and may use any remaining funds for supplemental benefits on the FHIX marketplace. (e) The corporation shall notify an enrollee of his or her premium credit amount and how to access the FHIX marketplace selection process. (f) Choice counseling and customer service must be provided in accordance with s (2) and (4). (g) Enrollees under s must transition to the FHIX marketplace by September 30, Section 10. Section , Florida Statutes, is created to read: Program operation and management. In order to implement ss : (1) The Agency for Health Care Administration shall do all of the following: (a) Contract with the corporation for the development, implementation, and administration of the Florida Health Insurance Affordability Exchange Program and for the release of any federal, state, or other funds appropriated to the corporation. (b) Administer Phase One of FHIX. (c) Provide administrative support to the FHIX Workgroup under s (d) Transition the FHIX enrollees to the FHIX marketplace beginning January 1, 2016, in accordance with the transition workplan. Stakeholders that serve low-income individuals and families must be consulted during the implementation and transition process through a public input process. All regions Page 17 of 49

18 must complete the transition no later than April 1, (e) Timely transmit enrollee information to the corporation. (f) Beginning with Phase Two, determine annually the riskadjusted rate to be paid per month based on historical utilization and spending data for the medical and behavioral health of this population, projected forward, and adjusted to reflect the eligibility category, medical and dental trends, geographic areas, and the clinical risk profile of the enrollees. (g) Transfer to the corporation such funds as approved in the General Appropriations Act for the premium credits. (h) Encourage Medicaid managed care plans to apply as vendors to the marketplace to facilitate continuity of care and family care coordination. (2) The Department of Children and Families shall, in coordination with the corporation, the agency, and the Florida Healthy Kids Corporation, determine eligibility of applications and application renewals for FHIX in accordance with s and shall transmit eligibility determination information on a timely basis to the agency and corporation. (3) The Florida Healthy Kids Corporation shall do all of the following: (a) Retain its duties and responsibilities under s for Phase One and Phase Two of the program. (b) Provide customer service for the FHIX marketplace, in coordination with the agency and the corporation. (c) Transfer funds and provide financial support to the FHIX marketplace, including the collection of monthly cost Page 18 of 49

19 sharing. (d) Conduct financial reporting related to such activities, in coordination with the corporation and the agency. (e) Coordinate activities for the program with the agency, the department, and the corporation. (4) Florida Health Choices, Inc., shall do all of the following: (a) Begin the development of FHIX during Phase One. (b) Implement and administer Phase Two and Phase Three of the FHIX marketplace and the ongoing operations of the program. (c) Offer health benefits coverage packages on the FHIX marketplace, including plans compliant with the Affordable Care Act. (d) Offer FHIX enrollees a choice of at least two plans per county at each benefit level which meet the requirements under the Affordable Care Act. (e) Provide an opportunity for participation in Medicaid managed care plans if those plans meet the requirements of the FHIX marketplace. (f) Offer enhanced or customized benefits to FHIX marketplace enrollees. (g) Provide sufficient staff and resources to meet the program needs of enrollees. (h) Provide an opportunity for plans contracted with or previously contracted with the Florida Healthy Kids Corporation under s to participate with FHIX if those plans meet the requirements of the program. Section 11. Section , Florida Statutes, is created to read: Page 19 of 49

20 Long-term reorganization. The FHIX Workgroup is created to facilitate the implementation of FHIX and to plan for a multiyear reorganization of the state s insurance affordability programs. The FHIX Workgroup consists of two representatives each from the agency, the department, the Florida Healthy Kids Corporation, and Florida Health Choices, Inc. An additional representative of the agency serves as chair. The FHIX Workgroup must hold its organizational meeting no later than 30 days after the effective date of this act and must meet at least bimonthly. The role of the FHIX Workgroup is to make recommendations to the agency. The responsibilities of the workgroup include, but are not limited to: (1) Recommend a Phase Two implementation plan no later than October 1, (2) Review network and access standards for plans and products. (3) Assess readiness and recommend actions needed to reorganize the state s insurance affordability programs for each phase or region. If a phase or region receives a nonreadiness recommendation, the agency must notify the Legislature of that recommendation, the reasons for such a recommendation, and proposed plans for achieving readiness. (4) Recommend any proposed change to the Title XIX-funded or Title XXI-funded programs based on the continued availability and reauthorization of the Title XXI program and its federal funding. (5) Identify duplication of services among the corporation, the agency, and the Florida Healthy Kids Corporation currently and under FHIX s proposed Phase Three program. Page 20 of 49

21 (6) Evaluate any fiscal impacts based on the proposed transition plan under Phase Three. (7) Compile a schedule of impacted contracts, leases, and other assets. (8) Determine staff requirements for Phase Three. (9) Develop and present a final transition plan that incorporates all elements under this section no later than December 1, 2015, in a report to the Governor, the President of the Senate, and the Speaker of the House of Representatives. Section 12. Section , Florida Statutes, is created to read: Federal participation. The agency may seek federal approval to implement FHIX. Section 13. Section , Florida Statutes, is created to read: Program expiration. The Florida Health Insurance Affordability Exchange Program expires at the end of Phase One if the state does not receive federal approval for Phase Two or at the end of the state fiscal year in which any of these conditions occurs: (1) The federal match contribution falls below 90 percent. (2) The federal match contribution falls below the increased Federal Medical Assistance Percentage for medical assistance for newly eligible mandatory individuals as specified in the Affordable Care Act. (3) The federal match for the FHIX program and the Medicaid program are blended under federal law or regulation in such a manner that causes the overall federal contribution to diminish when compared to separate, nonblended federal contributions. Page 21 of 49

22 Section 14. Section , Florida Statutes, is repealed. Section 15. Section , Florida Statutes, is amended to read: Florida Health Choices Program. (1) LEGISLATIVE INTENT. The Legislature finds that a significant number of the residents of this state do not have adequate access to affordable, quality health care. The Legislature further finds that increasing access to affordable, quality health care can be best accomplished by establishing a competitive market for purchasing health insurance and health services. It is therefore the intent of the Legislature to create and expand the Florida Health Choices Program to: (a) Expand opportunities for Floridians to purchase affordable health insurance and health services. (b) Preserve the benefits of employment-sponsored insurance while easing the administrative burden for employers who offer these benefits. (c) Enable individual choice in both the manner and amount of health care purchased. (d) Provide for the purchase of individual, portable health care coverage. (e) Disseminate information to consumers on the price and quality of health services. (f) Sponsor a competitive market that stimulates product innovation, quality improvement, and efficiency in the production and delivery of health services. (2) DEFINITIONS. As used in this section, the term: (a) Corporation means the Florida Health Choices, Inc., established under this section. Page 22 of 49

23 (b) Corporation s marketplace means the single, centralized market established by the program that facilitates the purchase of products made available in the marketplace. (c) Florida Health Insurance Affordability Exchange Program or FHIX is the program created under ss for low-income, uninsured residents of this state. (d)(c) Health insurance agent means an agent licensed under part IV of chapter 626. (e)(d) Insurer means an entity licensed under chapter 624 which offers an individual health insurance policy or a group health insurance policy, a preferred provider organization as defined in s , an exclusive provider organization as defined in s , or a health maintenance organization licensed under part I of chapter 641, or a prepaid limited health service organization or discount medical plan organization licensed under chapter 636, or a managed care plan contracted with the Agency for Health Care Administration under the managed medical assistance program under part IV of chapter 409. (f) Patient Protection and Affordable Care Act or Affordable Care Act means Pub. L. No , as further amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. No , and any amendments to or regulations or guidance under those acts. (g)(e) Program means the Florida Health Choices Program established by this section. (3) PROGRAM PURPOSE AND COMPONENTS. The Florida Health Choices Program is created as a single, centralized market for the sale and purchase of various products that enable Page 23 of 49

24 individuals to pay for health care. These products include, but are not limited to, health insurance plans, health maintenance organization plans, prepaid services, service contracts, and flexible spending accounts. The components of the program include: (a) Enrollment of employers. (b) Administrative services for participating employers, including: 1. Assistance in seeking federal approval of cafeteria plans. 2. Collection of premiums and other payments. 3. Management of individual benefit accounts. 4. Distribution of premiums to insurers and payments to other eligible vendors. 5. Assistance for participants in complying with reporting requirements. (c) Services to individual participants, including: 1. Information about available products and participating vendors. 2. Assistance with assessing the benefits and limits of each product, including information necessary to distinguish between policies offering creditable coverage and other products available through the program. 3. Account information to assist individual participants with managing available resources. 4. Services that promote healthy behaviors. 5. Health benefits coverage information about health insurance plans compliant with the Affordable Care Act. 6. Consumer assistance and enrollment services for the Page 24 of 49

25 Florida Health Insurance Affordability Exchange Program, or FHIX. (d) Recruitment of vendors, including insurers, health maintenance organizations, prepaid clinic service providers, provider service networks, and other providers. (e) Certification of vendors to ensure capability, reliability, and validity of offerings. (f) Collection of data, monitoring, assessment, and reporting of vendor performance. (g) Information services for individuals and employers. (h) Program evaluation. (4) ELIGIBILITY AND PARTICIPATION. Participation in the program is voluntary and shall be available to employers, individuals, vendors, and health insurance agents as specified in this subsection. (a) Employers eligible to enroll in the program include those employers that meet criteria established by the corporation and elect to make their employees eligible through the program. (b) Individuals eligible to participate in the program include: 1. Individual employees of enrolled employers. 2. Other individuals that meet criteria established by the corporation. (c) Employers who choose to participate in the program may enroll by complying with the procedures established by the corporation. The procedures must include, but are not limited to: 1. Submission of required information. Page 25 of 49

26 Compliance with federal tax requirements for the establishment of a cafeteria plan, pursuant to s. 125 of the Internal Revenue Code, including designation of the employer s plan as a premium payment plan, a salary reduction plan that has flexible spending arrangements, or a salary reduction plan that has a premium payment and flexible spending arrangements. 3. Determination of the employer s contribution, if any, per employee, provided that such contribution is equal for each eligible employee. 4. Establishment of payroll deduction procedures, subject to the agreement of each individual employee who voluntarily participates in the program. 5. Designation of the corporation as the third-party administrator for the employer s health benefit plan. 6. Identification of eligible employees. 7. Arrangement for periodic payments. 8. Employer notification to employees of the intent to transfer from an existing employee health plan to the program at least 90 days before the transition. (d) All eligible vendors who choose to participate and the products and services that the vendors are permitted to sell are as follows: 1. Insurers licensed under chapter 624 may sell health insurance policies, limited benefit policies, other risk-bearing coverage, and other products or services. 2. Health maintenance organizations licensed under part I of chapter 641 may sell health maintenance contracts, limited benefit policies, other risk-bearing products, and other products or services. Page 26 of 49

27 Prepaid limited health service organizations may sell products and services as authorized under part I of chapter 636, and discount medical plan organizations may sell products and services as authorized under part II of chapter Prepaid health clinic service providers licensed under part II of chapter 641 may sell prepaid service contracts and other arrangements for a specified amount and type of health services or treatments. 5. Health care providers, including hospitals and other licensed health facilities, health care clinics, licensed health professionals, pharmacies, and other licensed health care providers, may sell service contracts and arrangements for a specified amount and type of health services or treatments. 6. Provider organizations, including service networks, group practices, professional associations, and other incorporated organizations of providers, may sell service contracts and arrangements for a specified amount and type of health services or treatments. 7. Corporate entities providing specific health services in accordance with applicable state law may sell service contracts and arrangements for a specified amount and type of health services or treatments. A vendor described in subparagraphs may not sell products that provide risk-bearing coverage unless that vendor is authorized under a certificate of authority issued by the Office of Insurance Regulation and is authorized to provide coverage in the relevant geographic area. Otherwise eligible vendors may be excluded from participating in the program for deceptive or Page 27 of 49

28 predatory practices, financial insolvency, or failure to comply with the terms of the participation agreement or other standards set by the corporation. (e) Eligible individuals may participate in the program voluntarily. Individuals who join the program may participate by complying with the procedures established by the corporation. These procedures must include, but are not limited to: 1. Submission of required information. 2. Authorization for payroll deduction, if applicable. 3. Compliance with federal tax requirements. 4. Arrangements for payment. 5. Selection of products and services. (f) Vendors who choose to participate in the program may enroll by complying with the procedures established by the corporation. These procedures may include, but are not limited to: 1. Submission of required information, including a complete description of the coverage, services, provider network, payment restrictions, and other requirements of each product offered through the program. 2. Execution of an agreement to comply with requirements established by the corporation. 3. Execution of an agreement that prohibits refusal to sell any offered product or service to a participant who elects to buy it. 4. Establishment of product prices based on applicable criteria. 5. Arrangements for receiving payment for enrolled participants. Page 28 of 49

29 Participation in ongoing reporting processes established by the corporation. 7. Compliance with grievance procedures established by the corporation. (g) Health insurance agents licensed under part IV of chapter 626 are eligible to voluntarily participate as buyers representatives. A buyer s representative acts on behalf of an individual purchasing health insurance and health services through the program by providing information about products and services available through the program and assisting the individual with both the decision and the procedure of selecting specific products. Serving as a buyer s representative does not constitute a conflict of interest with continuing responsibilities as a health insurance agent if the relationship between each agent and any participating vendor is disclosed before advising an individual participant about the products and services available through the program. In order to participate, a health insurance agent shall comply with the procedures established by the corporation, including: 1. Completion of training requirements. 2. Execution of a participation agreement specifying the terms and conditions of participation. 3. Disclosure of any appointments to solicit insurance or procure applications for vendors participating in the program. 4. Arrangements to receive payment from the corporation for services as a buyer s representative. (5) PRODUCTS. (a) The products that may be made available for purchase through the program include, but are not limited to: Page 29 of 49

30 Health insurance policies. 2. Health maintenance contracts. 3. Limited benefit plans. 4. Prepaid clinic services. 5. Service contracts. 6. Arrangements for purchase of specific amounts and types of health services and treatments. 7. Flexible spending accounts. (b) Health insurance policies, health maintenance contracts, limited benefit plans, prepaid service contracts, and other contracts for services must ensure the availability of covered services. (c) Products may be offered for multiyear periods provided the price of the product is specified for the entire period or for each separately priced segment of the policy or contract. (d) The corporation shall provide a disclosure form for consumers to acknowledge their understanding of the nature of, and any limitations to, the benefits provided by the products and services being purchased by the consumer. (e) The corporation must determine that making the plan available through the program is in the interest of eligible individuals and eligible employers in the state. (6) PRICING. Prices for the products and services sold through the program must be transparent to participants and established by the vendors. The corporation may shall annually assess a surcharge for each premium or price set by a participating vendor. Any The surcharge may not be more than 2.5 percent of the price and shall be used to generate funding for administrative services provided by the corporation and payments Page 30 of 49

31 to buyers representatives; however, a surcharge may not be assessed for products and services sold in the FHIX marketplace. (7) THE MARKETPLACE PROCESS. The program shall provide a single, centralized market for purchase of health insurance, health maintenance contracts, and other health products and services. Purchases may be made by participating individuals over the Internet or through the services of a participating health insurance agent. Information about each product and service available through the program shall be made available through printed material and an interactive Internet website. (a) Marketplace purchasing. A participant needing personal assistance to select products and services shall be referred to a participating agent in his or her area. 1.(a) Participation in the program may begin at any time during a year after the employer completes enrollment and meets the requirements specified by the corporation pursuant to paragraph (4)(c). 2.(b) Initial selection of products and services must be made by an individual participant within the applicable open enrollment period. 3.(c) Initial enrollment periods for each product selected by an individual participant must last at least 12 months, unless the individual participant specifically agrees to a different enrollment period. 4.(d) If an individual has selected one or more products and enrolled in those products for at least 12 months or any other period specifically agreed to by the individual participant, changes in selected products and services may only be made during the annual enrollment period established by the Page 31 of 49

32 corporation. 5.(e) The limits established in subparagraphs 2., 3., and 4. paragraphs (b)-(d) apply to any risk-bearing product that promises future payment or coverage for a variable amount of benefits or services. The limits do not apply to initiation of flexible spending plans if those plans are not associated with specific high-deductible insurance policies or the use of spending accounts for any products offering individual participants specific amounts and types of health services and treatments at a contracted price. (b) FHIX marketplace purchasing. 1. Participation in the FHIX marketplace may begin at any time during the year. 2. Initial enrollment periods for certain products selected by an individual enrollee which are noncompliant with the Affordable Care Act may be required to last at least 12 months, unless the individual participant specifically agrees to a different enrollment period. (8) CONSUMER INFORMATION. The corporation shall: (a) Establish a secure website to facilitate the purchase of products and services by participating individuals. The website must provide information about each product or service available through the program. (b) Inform individuals about other public health care programs. (9) RISK POOLING. The program may use methods for pooling the risk of individual participants and preventing selection bias. These methods may include, but are not limited to, a postenrollment risk adjustment of the premium payments to the Page 32 of 49

33 vendors. The corporation may establish a methodology for assessing the risk of enrolled individual participants based on data reported annually by the vendors about their enrollees. Distribution of payments to the vendors may be adjusted based on the assessed relative risk profile of the enrollees in each risk-bearing product for the most recent period for which data is available. (10) EXEMPTIONS. (a) Products, other than the products set forth in subparagraphs (4)(d)1.-4., sold as part of the program are not subject to the licensing requirements of the Florida Insurance Code, as defined in s or the mandated offerings or coverages established in part VI of chapter 627 and chapter 641. (b) The corporation may act as an administrator as defined in s but is not required to be certified pursuant to part VII of chapter 626. However, a third party administrator used by the corporation must be certified under part VII of chapter 626. (c) Any standard forms, website design, or marketing communication developed by the corporation and used by the corporation, or any vendor that meets the requirements of paragraph (4)(f) is not subject to the Florida Insurance Code, as established in s (11) CORPORATION. There is created the Florida Health Choices, Inc., which shall be registered, incorporated, organized, and operated in compliance with part III of chapter 112 and chapters 119, 286, and 617. The purpose of the corporation is to administer the program created in this section and to conduct such other business as may further the Page 33 of 49